Refill Requests
Please allow for 3 business days for completion of your request unless prescription is expedited.
Select Your Provider
*
Please Select
Robert M. Slayden, M.D.
Lyndon D. Waugh, M.D.
LeNora Ashley, M.Ed., M.D.
Todd Iwanicki, M.D.
Susan S. Kirsch, M.D.
Allison Nitsche, M.D., M.P.H.
Angel Luis Perez, M.D.
Elizabeth R. Slayden, M.D.
Name
*
First Name
Last Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Patient's Name
*
First Name
Last Name
Patient's Phone Number
Please enter a valid phone number.
Patient's Date of Birth
-
Month
-
Day
Year
Medication #1
*
Dosage
*
Number of Pills
*
Medication #2
Dosage
Number of Pills
Medication #3
Dosage
Number of Pills
Medication #4
Dosage
Number of Pills
Date of last appointment
-
Month
-
Day
Year
Pharmacy Name
*
Pharmacy Phone Number
*
Pharmacy Address including zip code
*
Please include the zip code
Is this a different pharmacy from your last request?
*
Yes
No
Additional Comments (optional)
Expedited?
*
Yes ($45) Outside of Appointment Fee
No ($25) Outside of Appointment Fee
Submit
Should be Empty: